All posts by Diem-Khanh V Nguyen

The outcomes of Partners in Health’s (PIH’s) previous interventions imply that partnerships with community health leaders play a critical role in the success of global health programs. While these leaders are invaluable, their lives are not treated as such, especially when compared to the lives of foreign aid workers. This discrepancy indicates a rooted hierarchical structure in foreign aid groups – even in ones like PIH that recognize the necessity of collaborating with individuals who belong to the communities that are receiving aid.

PIH’s health care delivery model factors in the requisite of fostering and relying on community partnerships. This component has proven to be a critical contributor to PIH’s global health programs, which focus on combining horizontal and vertical care by integrating aggressive infectious disease treatment and structural reformation. (1) For example, PIH’s ‘Proje Veye Sante’ largely relied on “accompagnateurs,” or paid community health workers, to “interface between the clinic and the community.” (2, 3) As shown by the project’s outcomes, the success of health interventions is contingent on decreasing structural barriers through various services (e.g. provision of food, transportation, etc.) and, accordingly, on the participation of community health leaders who conduct these services. (4)

In a sense, the community members’ roles in PIH’s efforts illustrate their resilience and leadership in the face of inequality and structural violence. Rather than the community depending exclusively on an NGO to work for them, the NGO instead relies on the community in order to make a sustainable impact. This interdependent relationship also draws attention to PIH necessarily collaborating with community members to augment its biosocial view and to better understand how to meet local needs. This is seen in the story of Haitian Catholic priest and psychologist Père Eddy, who has served as director of Zanmi Lasante’s (as PIH is known in Haiti) mental health program since 2005. (5) Zanmi Lasante’s HIV and tuberculosis program recruited Père Eddy, a past counselor for sexually abused teenagers and for victims of post-traumatic stress after 2004’s coup d’etat, in order to provide better assistance to patients who were dealing with depression, psychosis, social isolation, and stigma. (6) There, he “trained social workers how to meet their patients’ psychological needs.” (7) He understood so well his community/community-based work that his methods “were later used by PIH community health workers in settlements for displaced people and were adopted by the Haitian government to help mourners nationwide.” (8) Overall, Père Eddy’s background not only as a psychologist and pastor, but also as a Haitian citizen who has experienced social inequalities and violence first-hand, provides him with a more appropriate skill-set for delivering care to the population of interest and for educating PIH volunteers.

While local health workers ostensibly play just as valuable a role in PIH’s outcomes as PIH volunteers (professionals, logisticians, etc.) do, their lives are less valued than their foreign partners’. When an American PIH volunteer in Sierra Leone contracted Ebola, he was quickly transferred to the United States for treatment. (9) The same level of care was not provided for native community health leaders: Usman Mohamed Koroma, “a ministry employee who helped oversee infection prevention and control at the site,” contracted Ebola the same week but had to wait two days before being moved to Sierra Leone’s “British-run treatment unit set up for sick health workers.” (10) Thus, despite being colleagues both essential for PIH’s work, “one [received] arguably the best Ebola care in the world [while] the other [received] the best Ebola care available in one of the poorest countries in the world.” (11)

Why, in an organization like PIH that identifies the importance of community health advocates, is there preferential health treatment for foreigners? There are potentially several factors that contribute to this disparity. Nevertheless, this situation highlights the inherent hierarchial structure of foreign aid: the best treatment is reserved for those who hold the most power – for those who, driven by morality but under no obligation, have entered and brought resources to a foreign country. On the other hand, community health leaders, who belong to the population that is receiving aid, often derive the opportunity to showcase their agency from the foundation laid by global health organizations. They are therefore seen (and treated) as lower in the hierarchal configuration; their ability to help their communities necessitates the foreign aid organization being present — not because they have no agency, but because the structural inequalities they face obstruct their agency. Only when organizations like PIH are present to diminish fundamental inequalities — by providing financial assistance and resources — are community health leaders able to further help their fellow citizens. Perhaps, though, despite PIH’s attempts to decrease structural violence by meeting basic and financial needs, the underlying inequalities of the community they are attempting to improve pervades and is reflected by their work.

Update:

Hi Everyone,

This is an update to my blog post based on the discussions that were presented in the comment section. Before I address some of my new thoughts/conclusions, I want to clarify my opinion on PIH. I think that PIH executes great work; its model (described in the readings) is quite effective, and the administrators/members have designed effective methods in order to create large impacts on communities that need aid. Furthermore, I believe that PIH does work under the idea that all lives are equal; in fact, as we discussed in class, PIH is perhaps designed to provide a preferential option for the poor (i.e. they seek to act on inequality). My blog, therefore, was not meant to completely condemn PIH and render it hypocritical/discriminatory but rather to present a concern I have about PIH’s limitations. While PIH may want to provide equal care for all of its members (Fink’s article did indicate that PIH volunteers tried to negotiate and make several calls in order to get Usman Koroma the help he needed), they are sometimes unable to. Why is this? This is one of the questions I was trying to address, and I originally proposed the inherent hierarchal nature of NGO work as a potential answer.

I’ve thought a lot about this question since, and I have some new ideas that I’d like to share. I think that the resource-poor setting in which NGO takes place plays a large role in the preferential treatment to foreign aid workers. NGOs like PIH may emphasize this idea of ‘getting funds if you need them,’ but realistically, there are financial limitations that prevent everyone from getting access to equal care. (If there weren’t financial limitations, why wouldn’t PIH try to fly every sick person to a country with better health services?) These financial – and logistical – limitations become even more visible in the event of an emergency like the spread of ebola to volunteers. (I’m using the word ‘emergency’ in a specific way right now, but I do acknowledge that it’s difficult to define what exactly an ‘emergency’ is.) Therefore, NGOs have to make a decision about how to distribute their resources. And after more thought, I have identified three main factors that contribute to an NGO’s hierarchy and that influence an NGO’s decisions regarding allocation: 1) Place of Origin, 2) Academic Credentials/Expertise (I’m combining the two, though you identified them separately), and 3) Sphere of Influence (how much influence they have in a community — though this is hard to measure). Regarding the first point, I am assuming that foreigners are often the wealthier players in this situation; they are the people bringing resources into a country that lacks them. As for the second point, while all members (at all levels) are important to NGO work, I think it’s important to consider whether an NGO’s foundation in another country (infrastructure, health centers, logistics, etc.) would exist without the involvement of professionals.

Now that I’ve discussed more potential causes of preferential treatment, I want to focus on two of the questions I asked: Is it possible to eliminate the inherent hierarchical structure of global health organizations? Our classmates had varying opinions on this. Some argued that eliminating the hierarchy is possible. Yuki commented that NGO workers should place more value on the views of community members before doing their work to ensure that community health workers are valued as equal colleagues. Sara also shared a hope of eliminating the hierarchy. Methma, on the other hand, suggested that hierarchy is the nature of health care work and therefore cannot exactly be eliminated. I agreed with this but suggested that maybe some steps could be taken to reduce consequential inequalities of the hierarchy: perhaps instead of trying to completely dismantle the hierarchy, NGOs could give community health leaders higher positions within the hierarchy. By including them in decision-making processes and providing them with actual statuses, an NGO could possibly use its inherent hierarchy to further highlight the agency of the community. Another commenter, Niki, suggested that perhaps the problem we should focus on isn’t the hierarchy but rather safety regulations in general. After all, the lack of safety is what led to PIH’s volunteers contracting ebola in the first place. And I think Niki’s point raises yet another important idea to contemplate: as I stated in a comment, PIH strives to collaborate with governmental bodies/institutions (e.g. Sierra Leone health ministry) in an attempt to make health interventions more sustainable. This means that, unlike groups like Doctors Without Borders, PIH relies on the local government for protective gear and supplies. This obviously becomes a problem when safety lapses (e.g. faulty gear) occur because resources are less regulated. Although involving the government and making use of local resources may be critical to PIH creating self-sustaining health infrastructure, it seems like it also can be quite harmful (depending on the government’s capabilities).

Overall, maybe there is a way to abolish the hierarchy, but maybe there isn’t. Maybe we should direct our concern elsewhere. Clearly, this topic/debate is extremely multifaceted, but I hope that this blog and its comments have encouraged you to think about new ideas.

Who are more necessary, community health leaders or foreign volunteers/aid groups? Should both types of volunteers receive the same healthcare? If yes, should all members of the community also have equivalent access?

Is it possible to eliminate the inherent hierarchical structure of global health organizations? Is doing so necessary?

What factors contribute to the preferential treatment of foreign aid workers?